Treatment of brain arteriovenous malformations with high-flow arteriovenous fistulas: risk and complications associated with endovascular embolization in multimodality treatment

Object High-flow fistulas associated with brain arteriovenous malformations (AVMs) pose a significant challenge to both stereotactic radiosurgery (SRS) and surgical treatment. The purpose of this study was to examine the outcomes of multimodality treatment of AVMs in association with a large arteriovenous fistula (AVF), with a special focus on endovascular embolization and its associated complications. Methods One hundred ninety-two patients harboring cerebral AVMs underwent endovascular treatment in the authors' department between 1997 and 2003. Of these, the authors selected 74 patients presenting with an AVM associated with high-flow AVF(s) for a retrospective analysis based on the findings of superselective angiography. After endovascular embolization, 32 patients underwent resection, 33 underwent either SRS or hypofractionated stereotactic radiotherapy (HSRT), and 3 underwent both surgery and SRS. Six patients underwent embolization only. Immediate and midterm treatment outcomes were analyzed. Results Fifty-seven (77%) of the 74 patients had AVMs that were Spetzler-Martin Grade III or higher. A complete resection was achieved in all 32 patients. Of patients who underwent SRS/HSRT, 13 patients (39.3%) had either complete or > 90% obliteration of the AVM, and 2 patients (6.1%) had incomplete obliteration. Fourteen patients (42.4%) with residual AVM underwent repeated radiotherapy (and remain under observation). Of the 3 patients who underwent both SRS and resection, resection was complete in 2 and incomplete in one. No follow-up was obtained in 6 patients (8.1%). An endovascular complication was observed in 4 patients (5.4%). Fistula embolization was safely performed in every patient, whereas every endovascular complication was associated with other procedures such as nidus embolization. Conclusions Endovascular occlusion of the fistulous component was successfully achieved in every patient; every endovascular complication in this series was related to other procedures such as nidus embolization. The importance of the fistula treatment should be emphasized to minimize the endovascular complications and to maximize the treatment effect when a multimodality therapy is used to treat brain AVMs with large AVF.

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Complication Analysis of 469 Brain Arteriovenous Malformations Treated with N-Butyl Cyanoacrylate

Interventional Neuroradiology ◽

10.1177/159101990501100204 ◽

2005 ◽

Vol 11 (2) ◽

pp. 141-148 ◽

Cited By ~ 14

Author(s):

T. L. Li ◽

B. Fang ◽

X. Y. He ◽

C. Z. Duan ◽

Q. J. Wang ◽

...

Keyword(s):

Arteriovenous Malformations ◽

Endovascular Procedures ◽

Endovascular Embolization ◽

Neurological Deficits ◽

Embolization Therapy ◽

Brain Arteriovenous Malformations ◽

Ischemic Complications ◽

Brain Avms ◽

Special Strategy ◽

Low Rate

We independently assessed the frequency, severity and determinants of neurological deficits after endovascular embolization with NBCA of brain arteriovenous malformations (BAVMs) to have a better basis for making treatment decisions. All the charts of 469 BAVMs patients who underwent embolization with NBCA were reviewed. We analyzed the complications and their relation to angiographic features. The 469 patients were treated with 1108 endovascular procedures. Each met one to eight times, average 2.3 times. Eleven patients showed treatment-related complications, including four haemorrhagic and seven ischemic complications. Of these 11 cases, two died, two had persistent disabling deficits, and another seven suffered transient neurological deficits. Our finding suggests a low rate of disabling treatment complications for embolization of brain AVMs with NBCA in this center. The management of AVM patients who have high risk of embolization therapy should be treated by special strategy.

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Antiangiogenic agent as a novel treatment for pediatric intracranial arteriovenous malformations: case report

Journal of Neurosurgery Pediatrics ◽

10.3171/2019.7.peds1976 ◽

2019 ◽

Vol 24 (6) ◽

pp. 673-679 ◽

Cited By ~ 3

Author(s):

Ken Maynard ◽

Melissa LoPresti ◽

Ionela Iacobas ◽

Peter Kan ◽

Sandi Lam

Keyword(s):

Arteriovenous Malformations ◽

Treatment Options ◽

Multimodality Treatment ◽

Endovascular Embolization ◽

High Flow ◽

The Novel ◽

Intracranial Arteriovenous Malformations ◽

Genetic Pathways ◽

Common Cause ◽

Novel Treatment

Intracerebral arteriovenous malformations (AVMs) are high-flow collections of abnormal vessels and a common cause of pediatric intracranial hemorrhage. There are few treatment options available for AVMs not amenable to surgical resection, endovascular embolization, radiosurgery, or multimodality treatment. The authors sought to review the molecular and genetic pathways that have been implicated in the formation of AVMs, focusing on the possibility of medically targeting these pathways in the treatment of AVMs. In the novel case presented here, a pediatric patient who was diagnosed with an intracranial AVM unamenable to conventional treatments underwent alternative treatment with molecular pathway inhibitors.

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Brain Arteriovenous Malformations and Endovascular Treatment: Effect on Seizures

Interventional Neuroradiology ◽

10.1177/159101991001600105 ◽

2010 ◽

Vol 16 (1) ◽

pp. 39-45 ◽

Cited By ~ 17

Author(s):

X. Lv ◽

Y. Li ◽

C. Jiang ◽

X. Yang ◽

Z. Wu

Keyword(s):

Endovascular Treatment ◽

Arteriovenous Malformations ◽

Seizure Control ◽

Neurovascular Unit ◽

Clinical History ◽

Endovascular Embolization ◽

Seizure Type ◽

Brain Arteriovenous Malformations ◽

Brain Avms

We report our experience in treating patients with seizures associated with brain arteriovenous malformations (AVM) without a clinical history of intracranial hemorrhage. Between 2001 and 2003, the neurovascular unit at Beijing Tiantan Hospital treated 109 patients with brain AVM endovascularly. Thirty patients (27.5%) experienced seizures before treatment. We studied the following factors: sex, age, AVM size, AVM location, seizure type, duration of seizure history, endovascular treatment and AVM obliteration. Clinical follow-up was via telephone interview. Thirty patients with seizure disorders due to brain AVMs were endovascularly treated. The age of the patients ranged from eight to 55 years. There were 22 males and eight females. The AVMs were smaller than 3 cm in five patients, between 3 cm and 6 cm in 22, and larger than 6 cm in three. The most frequent location of the AVMs was in the frontal, followed by the parietal, temporal and occipital lobes. Sixty-seven embolization procedures were performed and total obliteration was achieved in four patients. Two patients developed a hemiparesis and three suffered temporary dysphasia after embolization. Two patients had visual field deficits. There were no deaths. The results of post-embolization seizure control during the average follow-up period of 80 months were excellent in 21 patients, good in four, fair in two and poor in three. Successful seizure control can be obtained with endovascular embolization.

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Efficiency of endovascular embolization and predictors of postoperative complications in patients with different types of brain arteriovenous malformations

Patologiya krovoobrashcheniya i kardiokhirurgiya ◽

10.21688/1681-3472-2019-1-54-60 ◽

2019 ◽

Vol 23 (1) ◽

pp. 54

Author(s):

A. S. Brusyanskaya ◽

A. L. Krivoshapkin ◽

K. Yu. Orlov ◽

A. A. Alshevskaya ◽

A. V. Moskalev ◽

...

Keyword(s):

Postoperative Complications ◽

Conflict Of Interest ◽

Arteriovenous Malformations ◽

Maximum Size ◽

Endovascular Embolization ◽

Early Postoperative Period ◽

Invasive Approach ◽

Brain Arteriovenous Malformations ◽

Different Types ◽

Brain Avms

Aim. (1) To evaluate the efficiency of endovascular embolization of brain arteriovenous malformations (AVMs) with seizure or hemorrhage in relation to radicalness and postoperative complication development and (2) to determine the predictors of postoperative complications after endovascular embolization of AVMs.Methods. In this retrospective study, we examined the treatment of 192 patients with brain AVMs with seizure (seizure group; n = 85) or hemorrhage (hemorrhage group; n = 107). All the patients underwent total endovascular embolization of the malformations, and the follow-up period was 12 months. The two different patient groups were identified, and the predictors of the development of adverse events (hemorrhagic and ischemic complications) in the early postoperative period (hospital stay) were determined.Results. Twelve months after control cerebral angiography was performed, recanalization was observed in 7 (8.2%) and 14 (13.1%) patients in the seizure and hemorrhage groups, respectively (p = 0.432). The frequency of complications was 20% and 29.9% in the seizure and hemorrhage groups, respectively (p = 0.162). The mortality rate during hospitalization was 0% and 9.3% in the seizure and hemorrhage groups, respectively (p = 0.026). Multivariate regression analysis revealed that a history of hemorrhage, the location of AVMs in functionally significant zones, and a large maximum size of AVMs are predictors of the development of postoperative complications.Conclusion. Endovascular embolization is an effective, minimally invasive approach for the treatment of different types of brain AVMs. Considering the natural risks of brain AVMs according to the literature, endovascular embolization is associated with a low frequency of early postoperative complications.Received 14 February 2019. Revised 24 May 2019. Accepted 28 May 2019.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.

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Endovascular transvenous cure for ruptured brain arteriovenous malformations in complex cases with high Spetzler-Martin grades

Journal of Neurosurgery ◽

10.3171/2014.9.jns141714 ◽

2015 ◽

Vol 122 (5) ◽

pp. 1229-1238 ◽

Cited By ~ 42

Author(s):

Christina Iosif ◽

Georges A. C. Mendes ◽

Suzana Saleme ◽

Sanita Ponomarjova ◽

Eduardo Pedrolo Silveira ◽

...

Keyword(s):

Arteriovenous Malformations ◽

Clinical Status ◽

Surgical Techniques ◽

Venous Drainage ◽

Endovascular Embolization ◽

Modified Rankin Scale ◽

Transvenous Embolization ◽

Scale Scores ◽

Therapeutic Decision Making ◽

Brain Avms

OBJECT Ruptured cerebral arteriovenous malformations (AVMs) with deep localization and high Spetzler-Martin grades are associated with considerable challenges regarding nidus eradication treatment. The authors report their experience with curative endovascular transvenous embolization in a series of patients harboring “untreatable” lesions. METHODS Between January 2008 and June 2013, a transvenous endovascular embolization protocol was implemented at the authors' institution for consecutive patients with ruptured brain AVMs that were considered incurable by classic endovascular and surgical techniques. Therapeutic decision making was based on Spetzler-Martin grades, AVM location, type of venous drainage, and angioarchitectural evaluation. Complete exclusion of the nidus was the objective of treatment. RESULTS Twenty patients (10 male and 10 female, mean age 36.7 ± 17.7 years) were included. Initial Spetzler-Martin grades were III–V for 90.0% of the patients. The lesions were deeply seated in 80% and in eloquent locations in 90% of cases. The preprocedural modified Rankin Scale score was 0–2 for 12 of the 20 patients (60.0%), 3 for 2 patients (10.0%), and 4 for 6 patients (30.0%). The postprocedural clinical status was unchanged for all patients. The procedure was technically feasible in all cases. Procedure-related mortality was 0%. Ninety percent of the patients were independent in their everyday lives (modified Rankin Scale Scores 0–2) at the 6-month follow-up. In all cases but one (95%) the embolization was curative, confirmed by selective DSA at 6 months and 18 months postintervention. CONCLUSIONS Single-session endovascular transvenous embolization seems to be a safe and effective curative treatment for patients harboring complex brain AVMs with high Spetzler-Martin grade.

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Concurrent decompression and resection versus decompression with delayed resection of acutely ruptured brain arteriovenous malformations

Journal of Neurosurgery ◽

10.3171/2021.8.jns211075 ◽

2021 ◽

pp. 1-8

Author(s):

Rajeev D. Sen ◽

Isaac Josh Abecassis ◽

Jason Barber ◽

Michael R. Levitt ◽

Louis J. Kim ◽

...

Keyword(s):

Intracranial Hypertension ◽

Scale Score ◽

Arteriovenous Malformations ◽

Endovascular Embolization ◽

Surgical Decompression ◽

Low Grade ◽

Brain Arteriovenous Malformations ◽

Significant Difference ◽

Delayed Group

OBJECTIVE Brain arteriovenous malformations (bAVMs) most commonly present with rupture and intraparenchymal hemorrhage. In rare cases, the hemorrhage is large enough to cause clinical herniation or intractable intracranial hypertension. Patients in these cases require emergent surgical decompression as a life-saving measure. The surgeon must decide whether to perform concurrent or delayed resection of the bAVM. Theoretical benefits to concurrent resection include a favorable operative corridor created by the hematoma, avoiding a second surgery, and more rapid recovery and rehabilitation. The objective of this study was to compare the clinical and surgical outcomes of patients who had undergone concurrent emergent decompression and bAVM resection with those of patients who had undergone delayed bAVM resection. METHODS The authors conducted a 15-year retrospective review of consecutive patients who had undergone microsurgical resection of a ruptured bAVM at their institution. Patients presenting in clinical herniation or with intractable intracranial hypertension were included and grouped according to the timing of bAVM resection: concurrent with decompression (hyperacute group) or separate resection surgery after decompression (delayed group). Demographic and clinical characteristics were recorded. Groups were compared in terms of the primary outcomes of hospital and intensive care unit (ICU) lengths of stay (LOSs). Secondary outcomes included complete obliteration (CO), Glasgow Coma Scale score, and modified Rankin Scale score at discharge and at the most recent follow-up. RESULTS A total of 35/269 reviewed patients met study inclusion criteria; 18 underwent concurrent decompression and resection (hyperacute group) and 17 patients underwent emergent decompression only with later resection of the bAVM (delayed group). Hyperacute and delayed groups differed only in the proportion that underwent preresection endovascular embolization (16.7% vs 76.5%, respectively; p < 0.05). There was no significant difference between the hyperacute and delayed groups in hospital LOS (26.1 vs 33.2 days, respectively; p = 0.93) or ICU LOS (10.6 vs 16.1 days, respectively; p = 0.69). Rates of CO were also comparable (78% vs 88%, respectively; p > 0.99). Medical complications were similar in the two groups (33% hyperacute vs 41% delayed, p > 0.99). Short-term clinical outcomes were better for the delayed group based on mRS score at discharge (4.2 vs 3.2, p < 0.05); however, long-term outcomes were similar between the groups. CONCLUSIONS Ruptured bAVM rarely presents in clinical herniation requiring surgical decompression and hematoma evacuation. Concurrent surgical decompression and resection of a ruptured bAVM can be performed on low-grade lesions without compromising LOS or long-term functional outcome; however, the surgeon may encounter a more challenging surgical environment.

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Endovascular Advances for Brain Arteriovenous Malformations

Neurosurgery ◽

10.1227/neu.0000000000000176 ◽

2014 ◽

Vol 74 (suppl_1) ◽

pp. S74-S82 ◽

Cited By ~ 57

Author(s):

R. Webster Crowley ◽

Andrew F. Ducruet ◽

Cameron G. McDougall ◽

Felipe C. Albuquerque

Keyword(s):

Endovascular Treatment ◽

Surgical Resection ◽

Arteriovenous Malformations ◽

Treatment Options ◽

Brain Arteriovenous Malformations ◽

Short Period ◽

Cerebral Avms ◽

Brain Avms ◽

The Brain ◽

The Way

Abstract Arteriovenous malformations (AVMs) of the brain represent unique challenges for treating physicians. Although these lesions have traditionally been treated with surgical resection alone, advancements in endovascular and radiosurgical therapies have greatly expanded the treatment options for patients harboring brain AVMs. Perhaps no subspecialty within neurosurgery has seen as many advancements over a relatively short period of time as the endovascular field. A number of these endovascular innovations have been designed primarily for cerebral AVMs, and even those advancements that are not particular to AVMs have resulted in substantial changes to the way cerebral AVMs are treated. These advancements have enabled the embolization of cerebral AVMs to be performed either as a stand-alone treatment, or in conjunction with surgery or radiosurgery. Perhaps nothing has impacted the treatment of brain AVMs as substantially as the development of liquid embolics, most notably Onyx and n-butyl cyanoacrylate. However, of near-equal impact has been the innovations seen in the catheters that help deliver the liquid embolics to the AVMs. These developments include flow-directed catheters, balloon-tipped catheters, detachable-tipped catheters, and distal access catheters. This article aims to review some of the more substantial advancements in the endovascular treatment of brain AVMs and to discuss the literature surrounding the expanding indications for endovascular treatment of these lesions.

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Nongalenic arteriovenous fistulas: history of treatment and technology

Neurosurgical FOCUS ◽

10.3171/foc.2006.20.6.8 ◽

2006 ◽

Vol 20 (6) ◽

pp. 1-8 ◽

Cited By ~ 12

Author(s):

Kristen Upchurch ◽

Lei Feng ◽

Gary R. Duckwiler ◽

John G. Frazee ◽

Neil A. Martin ◽

...

Keyword(s):

Open Surgery ◽

Interventional Neuroradiology ◽

Endovascular Embolization ◽

High Flow ◽

Vascular Lesions ◽

Arteriovenous Fistulas ◽

The Past ◽

Technological Developments ◽

History Of ◽

Endovascular Technology

✓ Nongalenic cerebral arteriovenous fistulas (AVFs) are uncommon, high-flow vascular lesions first treated by Walter Dandy and his colleagues by using open surgery with ligation of the feeding artery. Due to advances in endovascular technology over the past four decades that make possible the control of high flow in AVFs, treatment has evolved from the sole option of surgery to include the alternative or adjunct option of endovascular embolization. The authors of this review discuss the history of nongalenic AVF treatment, including techniques of both surgery and interventional neuroradiology and the technological developments underlying them.

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